Healthcare Provider Details

I. General information

NPI: 1215074331
Provider Name (Legal Business Name): JAPHET GAZTAMBIDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CENTRO DE SALUD CONDUCTUAL DE AGUADILLA AVE. KENNEDY # 15
AGUADILLA PR
00603
US

IV. Provider business mailing address

P O BOX 7004 PONCE SCHOOL OF MEDICINE
PONCE PR
00732-7004
US

V. Phone/Fax

Practice location:
  • Phone: 787-840-2575
  • Fax: 787-840-8391
Mailing address:
  • Phone: 787-840-2575
  • Fax: 787-840-8391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number11940
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: